Titrated hypertonic/hyperoncotic solution for hypotensive fluid resuscitation during uncontrolled hemorrhagic shock in rats.
ABSTRACT In volume- or pressure-controlled hemorrhagic shock (HS) a bolus intravenous infusion of hypertonic/hyperoncotic solution (HHS) proved beneficial compared to isotonic crystalloid solutions. During uncontrolled HS in animals, however, HHS by bolus increased blood pressure unpredictably, and increased blood loss and mortality. We hypothesized that a titrated i.v. infusion of HHS, compared to titrated lactated Ringer's solution (LR), for hypotensive fluid resuscitation during uncontrolled HS reduces fluid requirement, does not increase blood loss, and improves survival.
We used our three-phased uncontrolled HS outcome model in rats. HS phase I began with blood withdrawal of 3 ml/100g over 15 min, followed by tail amputation. Then, hydroxyethyl starch 10% in NaCl 7.2% was given i.v. to the HHS group (n=10) and LR to the control group (n=10), both titrated to prevent mean arterial pressure (MAP) from falling below 40 mmHg during HS time 20-90 min. At HS 90 min, resuscitation phase II of 180 min began with hemostasis, return of all the blood initially shed, plus fluids i.v. as needed to maintain normotension (MAP>or=70 mmHg). Liver dysoxia was monitored as increase in liver surface pCO2 during phases I and II. Observation phase III was to 72 h.
During HS, preventing a decrease in MAP below 40 mmHg required HHS 4.9+/-0.6 ml/kg (all data mean+/-S.E.M.), compared to LR 62.2+/-16.6 ml/kg (P<0.001), with no group difference in MAP. Uncontrolled blood loss during HS from the tail stump was 13.3+/-1.9 ml/kg with HHS infusion, versus 12.6+/-2.5 ml/kg with LR infusion (P=0.73). Serum sodium concentrations were moderately elevated at the end of HS in the HHS group (149+/-3 mmol/l) versus the LR group (139+/-1 mmol/l) (P=0.001), and remained elevated throughout. Liver pCO2 increased during HS in both groups equally (P<0.001 versus baseline), and tended to return to baseline levels at the end of HS. Blood gas and lactate values throughout did not differ between groups. During HS, 2 of 10 rats in the HHS group versus 0 of 10 in the LR group died (P=0.47). There was no difference between HHS and LR groups in survival rates to 72 h (3 of 10 in the HHS group versus 2 of 10 in the LR group) (P=1.0). Survival times, by life table analysis, were not different (P=0.75).
In prolonged uncontrolled HS, a titrated i.v. infusion of HHS can maintain controlled hypotension with only one-tenth of the volume of LR required, without increasing blood loss. This titrated HHS strategy may not increase the chance of long-term survival.
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ABSTRACT: To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC). Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models. Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements. Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.01/2014; DOI:10.1111/vec.12138
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ABSTRACT: Die traumatische thorakale Aortenruptur stellt eine lebensbedrohliche Verletzung der Aorta dar, die als Begleitverletzung nach stumpfem Thoraxtrauma oder im Rahmen eines Polytraumas vorkommen kann. In Abhängigkeit vom Ausmaß der Zerreißung der Aortenwand ist diese Gefäßverletzung mit einer hohen primären Letalität und einem relevanten sekundären Rupturrisiko im weiteren Verlauf verbunden. Bei der präklinischen Beurteilung können der linksthorakale Schmerz, ein abgeschwächtes linksseitiges Atemgeräusch mit zunehmender Dyspnoe und Tachykardie sowie ein abgeschwächter Puls an den unteren Extremitäten entsprechend einer Pseudokoarktation Hinweise für eine thorakale Aortenruptur geben. Die präklinische Therapie besteht in der Stabilisierung der Vitalfunktionen und der Behandlung des möglichen Schockzustands. Während die offene operative Therapie der traumatischen Aortenruptur bisher vorwiegend durch Direktnaht oder Gefäßinterponat mit kurzer Abklemmung der thorakalen Aorta oder extrakorporaler Zirkulation durchgeführt wurde, gewinnt die endovaskuläre thorakale Stentgraft-Implantation zunehmend an Bedeutung. Die bisher publizierten Ergebnisse zur endovaskulären Therapie der traumatischen Aortenruptur und auch eigene Erfahrungen weisen darauf hin, dass die Einführung der thorakalen Stentgraft-Implantation zu einem Verfahrenswechsel mit der Möglichkeit der frühzeitigen Primärversorgung der lebensbedrohlichen Verletzung ohne zusätzlichen Thoraxeingriff geführt hat. Regelmäßige Kontrolluntersuchungen sind erforderlich, um mögliche Dislokationen der Stentgrafts oder Leckagen zu erkennen und notwendige endovaskuläre oder offen chirurgische Sekundäreingriffe durchführen zu können.Der Anaesthesist 08/2008; 57(8). · 0.74 Impact Factor
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ABSTRACT: To evaluate the effects of various fluids on uncontrolled hemorrhagic shock (UHS). Controversy exists over the appropriate doses and types of fluids for best treating UHS. This study evaluated the effects of hypertonic saline (HTS), normal saline (NS), and no fluid resuscitation (NFR) on UHS. Thirty goats were anesthetized and underwent right leg ablation. The animals were randomly assigned to equal NFR, HTS, and NS groups. The following features of UHS were analyzed: hemoglobin, heart rate, blood loss, mean arterial pressure, bleeding time, and pH. Animals were sacrificed two hours after ablation. All of the goats who received HTS died within 60 minutes. Four goats in the NS group and one goat in the NFR group died within 120 minutes. The NFR group had significantly higher hemoglobin values than the NS and HTS groups at the end of the trial. Blood loss in the HTS group was greater than in the other two groups (p<0.05). The NS group had higher blood loss than the NFR group (p<0.05). Mean arterial pressure in the HTS group decreased sharply toward zero within the first 60 minutes. In the NFR and NS groups, mean arterial pressure was higher than in the HTS group (p<0.05), and remained constant at 60mmHg after 35 minutes. The NFR group had higher pH values compared to the other two groups (p<0.05). Our study demonstrated that HTS is not suitable for treating UHS when compared to NFR and NS. Goats treated with NFR had superior values for all UHS features, including hemoglobin, pH, blood pressure, and bleeding time, compared to those treated with HTS and NS. Pre-hospital field treatment with NS or HTS may worsen the condition until surgical repair is accomplished.Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery: TJTES 11/2013; 19(6):500-506. DOI:10.5505/tjtes.2013.31799 · 0.38 Impact Factor